Report | Question ID | Question | Discussion | Answer | Year |
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20180026 | Solid Tumor Rules (2018)--Breast: How many primaries are accessioned when a prophylactic mastectomy reveals a final diagnosis of invasive tubular carcinoma, but the College of American Pathologists (CAP) Protocol includes ductal carcinoma in situ (DCIS) sized separately and it is not clear if these are different tumors? See Discussion. |
The patient was incidentally diagnosed with cancer on a prophylactic mastectomy, so there are no positive imaging findings to correlate the number of tumors/masses. The final diagnosis was invasive tubular carcinoma, and referred to the CAP Protocol. The CAP notes: However, it does not specify whether the single contiguous focus also includes the in situ component. The CAP goes on to note DCIS was present: The gross description does not provide any indication of either a single or multiple tumors/masses/lesions, though it was referred to as "Lesion 1" in the gross description with no indication of other lesions. The format of the CAP Protocol frequently does not specify whether the DCIS is a separate measured tumor, or if it is a component of the invasive tumor. This makes it difficult to determine whether the DCIS should be a separate primary when the invasive tumor is not also a type of ductal carcinoma. Per both the 2007 MP/H and 2018 Solid Tumor Rules, an invasive tubular carcinoma and a ductal carcinoma in situ would be multiple primaries if they were multiple tumors. Should we default to Rule M1: Abstract a single primary when it is not possible to determine if there is a single or multiple tumors? Or should we assume these are separate tumors because they were both sized, the focality only described a single invasive tumor, and the tumors are not both ductal carcinomas? |
Accession a single primary using Solid Tumor Rule M3. Based on the information provided, this was described as "Lesion 1' with no other lesions noted in the gross description. If the DCIS was a separate tumor, this would have been noted by the pathologist. Reminder, the breast CAP protocol is a checklist for pathologists to note their findings while reviewing the slides and/or specimen. The findings and notes should be consolidated into a final/synoptic report. |
2018 |
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20180096 | Reportability/Histology--Small intestine: Is a neuroendocrine microtumor of the duodenum a reportable tumor? See Discussion. |
This comment was added to the pathology report by the pathologist: A focus of neuroendocrine microtumor measured 350 micrometers, qualifying as a neuroendocrine microtumor. Focus was immunohistochemically positive for chromogranin and synaptophysin and negative for gastrin. The Ki-67/CD45 immunostain showed <1% positivity in microtumor. |
Neuroendocrine microtumor of the duodenum is reportable as 8240/3. "Microtumor" pertains to the size/amount of NET and not to a histologic type. |
2018 |
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20180113 | Solid Tumor Rules (2018)/Histology--Lung: What is the histology code of a 2018 lung cancer case with invasive non-mucinous adenocarcinoma? For non-mucinous carcinoma/adenocarcinoma, the Solid Tumor Rules have codes for microinvasive, minimally invasive, preinvasive, and in situ. Do we default to the microinvasive/minimally invasive code? |
Code histology to adenocarcinoma, NOS (8140/3). The World Health Organization and the College of American Pathologists no longer recognize non-mucinous carcinoma/adenocarcinoma, NOS. Pathologists are discouraged from using this term. Microinvasive/minimally invasive lung tumors have very specific criteria and these criteria do not apply to non-mucinous carcinoma, NOS. |
2018 | |
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20180109 | Date of diagnosis/Ambiguous terminology--Cervix Uteri: Is the date of diagnosis of a cervical pap smear done in December 2017, that states high-grade squamous intraepithelial lesion with features suspicious for invasion, followed by a cervical biopsy in 2018 positive for squamous cell carcinoma, in 2017? Is the ambiguous term used in the cytology in 2017 (suspicious for invasion) to determine diagnosis as the SEER manual states to use the ambiguous cytology as the date of diagnosis if confirmed later. |
Based on the information provided, this is a 2018 diagnosis. SEER has been asked to postpone implementing the instruction about using the date of the ambiguous cytology until 2019 or later. We will be removing that instruction from the draft 2018 SEER manual when it is finalized. |
2018 | |
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20180064 | Solid Tumor Rules (2018)/Recurrence--Breast: Does any recurrence within the multiple primaries-stated timeframe count, not those just in the primary site? See Discussion. |
A patient has a left breast cancer diagnosed in 2011; then has a "recurrence" in her lymph nodes in 2017. In 2018, she has a new left breast mass that is the same histology and behavior as the 2011 cancer. Based on the 2017 "recurrence" in the lymph nodes, this is not a new breast primary, is that correct? |
This is a single primary using 2018 Breast Solid Tumor Rule M11. Rule M8 does not apply because the patient was not clinically disease free for 5 years. We are interpreting the 2017 diagnosis as lymph node metastasis from the 2011 breast cancer diagnosis. |
2018 |
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20180087 | Solid Tumor Rules (2018)/Multiple Primaries--Brain: How many primaries are there and what M Rule applies when two tumors identified in the brain are pathologically proven to be glioblastoma, IDH-wild type and anaplastic astrocytoma per the pathology report final diagnosis, but the diagnosis comment and tumor board indicates multifocal glioblastoma is favored? See Discussion. |
The patient has one tumor each in the left parietal and left medial temporal lobe. The tumors were excised. The final diagnosis for the left parietal tumor is glioblastoma, IDH-wild type. he final diagnosis of the left medial temporal tumor is, at least anaplastic astrocytoma, WHO grade III; see comment. The comment states: There is a single focus of vascular hyperplasia, separate from neoplastic cells. No necrosis is identified. These findings on their own would warrant a diagnosis of anaplastic astrocytoma, WHO grade III. However, in the context of the patient's glioblastoma in the left parietal lobe, and imaging showing ring-enhancing lesions of the parietal and temporal lobes, this specimen is favored to be an un-sampled glioblastoma, WHO grade IV. The Solid Tumor Rules indicate we may no longer use terms like favor(s) to code the histology, leaving the final diagnosis as the priority source for coding histology per the Histology coding rules. The tumor board review confirmed that, despite the anaplastic astrocytoma on pathology, they felt strongly that this is a multifocal glioblastoma and not an anaplastic astrocytoma. Both the pathologist's comment and the tumor board's assessment indicate this patient does not have two primaries. However, the Solid Tumor Rules do not give priority to the tumor board's assessment over the pathology, and registrars are not to use ambiguous terms to code histology thus leaving the two histologies to consider. Per the Solid Tumor Rules, one tumor that is glioblastoma and one tumor that is anaplastic astrocytoma are multiple primaries per M11 (Abstract multiple primaries when separate, non-contiguous tumors are on different rows in Table 3 in the Equivalent Terms and Definitions. Timing is irrelevant). As a central registry, we cannot ask the pathologist or attending physician for clarification as suggested in Section 3 of the Malignant CNS and Peripheral Nerves Equivalent Terms and Definitions. We can only follow the current Solid Tumor Rules. In doing so, we would have to ignore both the pathologist's and tumor board's assessment that this patient has multifocal glioblastoma. Is there any concern that this will lead to over-reporting? |
Abstract separate primaries based on the two histology codes as these are separate tumors on different rows in Table 3 of the 2018 Solid Tumor Rules for Malignant CNS, Rule M11. The priority order for using documentation to identify histology for Malignant CNS is to use pathology/tissue from the resection over the tumor board. |
2018 |
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20180076 | Solid Tumor Rules (2018)/Histology--Head & Neck: Where does cytology rank on the Priority Order for Using Documentation to Identify Histology for Head and Neck primaries? See Discussion. |
Cytology is not listed in the Priority Order for Using Documentation to Identify Histology (Histology Coding Rules) in the Head and Neck schema. Other schemas do include cytology in the hierarchy below tissue from a biopsy or resection. Cytology is often less specific than histology, so one would expect cytology to be listed below tissue in this hierarchy. Was this an oversight? Or would cytology be equivalent to histology if it provided the most specific histology for the case? |
Instruction #5 in the Priority Order for Using Documentation to Identify Histology of the Head and Neck Solid Tumor Rules, Item 5.B., refers to cytology in the documentation though cytology is not listed before this. In H&N tumors, cytology is usually performed on lymph nodes and seldom on a primary tumor. Cytology will be added to H&N in the next update. |
2018 |
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20180112 | Solid Tumor Rules (2018)/Histology--Lung: What is the histology code of a non-small cell lung cancer (NSCLC), NOS as this is not on the AJCC list of histologies? See Discussion. |
A question was posted to CAnswer forum 9/26/18 and answered stating that 8046 is not on the AJCC list of histologies for the lung chapter in the 8th edition. If the final diagnosis on the pathology report is just NSCLC, NOS with no subtype/variant, what histology/solid tumor rule would I use? In this situation, I am not able to query the pathologist. Would I code the histology to 8010 as per AJCC post? |
Code NSCLC to 8046/3. Do not change a histology code simply to assign TNM to the case. AJCC does not determine histology coding. While pathologists are no longer encouraged to use NSCLC, it does not mean the term and code are obsolete. NSCLC could be any number of histologies such as adenocarcinoma or squamous carcinoma. A diagnosis of NSCLC indicates that the initial exam of the tissue did not identify a more specific type of NSCLC. Additional immunohistochemical testing is needed to determine the histology. Update the case if better information becomes available from subsequent tests/review. When analyzing the data, researchers and physicians will be able to identify the cases where the pathologist was unable to or did not perform further testing to determine a specific histology which drives treatment and survival. |
2018 |
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20180098 | Solid Tumor Rules (2018)/Histology: Please provide further explanation for prioritizing biomarkers in the histology coding rules. See Discussion. |
The 2018 Solid Tumor (ST) Rules General Rules state: For those sites/histologies which have recognized biomarkers, the biomarkers frequently identify the histologic type. Currently there are clinical trials being conducted to determine whether these biomarkers can be used to identify multiple primaries. Follow the Multiple Primary Rules; do not code multiple primaries based on biomarkers. Additionally, Biomarkers is at the top of the priority order to identify histology in several sections (it appears to be excluded from only Colon, Melanoma and Other sections). In the sections that include this rule, there is not much additional information on using biomarkers. Can you please provide further explanation for prioritizing biomarkers in the histology coding rules? For example, will the ST manual be updated when we need to look for specific biomarkers in a diagnosis? |
Instructions for biomarkers will be added to other site rules when applicable. The use of biomarkers to determine a specific histologic type is not yet a standard of care in the majority of cases. |
2018 |
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20180105 | 2018 Solid Tumor Rules/Histology--Lung: What is the appropriate histology code for the case below in the Discussion section? Is there a difference between adenocarcinoma in situ (bronchioloalveolar carcinoma), non-mucinous type (8252/2) and adenocarcinoma in-situ, mucinous? See Discussion. |
Procedure: Wedge, resection specimen, Laterality: Right, Tumor site: Right upper lobe, Tumor size: 1.0 cm in greatest dimension, Histologic type: Adenocarcinoma in-situ, mucinous, Histologic grade: N/A, Visceral pleura invasion: Not identified, Tumor extension: N/A, Margins: Uninvolved, Lymphocytosis. |
Assign 8253/2 for adenocarcinoma in situ, mucinous. New codes were added in 2018 for mucinous adenocarcinoma in situ for lung cancer only as all cases were not invasive. Pathologist are discouraged from using the term BAC. In-situ lung tumors can now be identified as either mucinous or non-mucinous and the appropriate ICD-O code should be assigned based on diagnosis. |
2018 |